Part Two
- Evaluation policies
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Policy: the hospital is committed to clarifying the areas and contents of the evaluation according to each department.
Purpose: to clarify the areas and contents of the assessment according to each section, which helps to provide appropriate medical care to the patient, reach an accurate diagnosis and develop a treatment plan.
Working procedures:
First: the Attending Physician:
1-the initial patient assessment should include familiarization with the personal history, the patient's complaint and the patient's family history.
2-the initial patient assessment should clarify the patient's medical history and medical examination, which contains (vital signs – examination of body systems by specialty and condition).
3-review the results of any evaluation of the patient outside the hospital (medical report) before the patient is admitted for treatment inside the man8hospital.
4-identify the patient's previous treatments and the extent of his response to them in order to :
* Determination of the initial diagnosis.
* Determine the required research for the patient.
* Develop an appropriate treatment plan.
* Identify the patient's medical care needs and choose the best care for him.
5-the doctor will re-examine the patient clinically after reviewing the patient's complete patient history within 24 hours of the patient's admission to the hospital, according to the patient history form and medical examination .
6-each of the sections determines the content of the medical evaluation according to the specialty and clinical manuals ( Cardiology, women, dialysis, premature babies ).
7-the doctor records the diagnosis, the result of the examination and the pathological history in the patient's file and signs it with the date and hour.
8-The Doctor re-evaluates the patient based on the results of tests and examinations and the progress of his health condition and registers and signs with writing the date and time in the patient's file.
Second, nursing :-
* Nursing evaluates the patient when the patient is admitted to the hospital using the nursing assessment form.
* The initial information and data are recorded when the patient enters the department with the nursing assessment form for the patient :
- Vital signs (pressure – pulse – respiratory rate-temperature).
- Weight and height.
- The presence of allergies.
- Assessment of pain.
- Assessment of skin condition.
- Evaluation of the patient in relation to the likelihood of a fall.
- Nutritional assessment.
- Assessment of motor activity.
- The patient's need for restriction or isolation.
- Familiarizing the patient with his rights, responsibilities, and hospital policy within 24 hours of admission.
III anesthesia:
* The anesthesiologist evaluates the patient's condition:
1-before giving anesthesia according to the pre anesthesia sheet form, the type of planned anesthesia is indicated.
2-observation and evaluation of the patient during anesthesia according to the model prepared for this.
3-evaluating the patient before leaving the recovery room according to the recovery model.
Fourth: physiotherapist (assessment of motor activity, functional, rehabilitation in case of need of the patient).
Fifth: the Attending Physician evaluates the nutritional needs of patients, especially cases that are sorted according to the evaluation
The nurse at the entrance.
Sixth: the social worker according to his job description ( he checks the satisfaction of patients, and does social research when the patient needs financial, material, educational, social support ).
Responsible: doctor-nursing-social worker.
Forms: (medical report - patient ticket – emergency form – nursing assessment – anesthesia sheet – physiotherapy form – patient satisfaction questionnaire ).
References: Egyptian accreditation standards.
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